- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.25 / $46.25 / $94.19
| Professional | | $46.25 | $46.25 | $94.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.04 / $105.04 / $105.04
| Facility | | $105.04 | $105.04 | $105.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.04 / $105.04 / $105.04
| Professional | | $105.04 | $105.04 | $105.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.27 / $116.27 / $116.27
| Facility | | $116.27 | $116.27 | $116.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.55 / $45.55 / $94.20
| Professional | | $45.55 | $45.55 | $94.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.79 / $47.35 / $52.56
| Professional | | $42.79 | $47.35 | $52.56 |